What have you been reading, hearing or TV viewing that has provoked some feelings of comfort or concern about what is happening in the world of medicine, medical care, treatment or science? Ethics is all about doing the right thing. Are you aware of any issues in medicine or biologic science which are being done right, could be improved or in fact represent totally unethical behavior?
Write about them here.. and I will too! ..Maurice (DoktorMo@aol.com)

REMINDER: I AM POSTING A NEW TOPIC ABOUT ONCE A WEEK OR PERHAPS TWICE A WEEK. HOWEVER, IF YOU DON'T FIND A NEW TOPIC POSTED, THERE ARE AS OF MARCH 2013 OVER 900 TOPIC THREADS TO WHICH YOU CAN READ AND WRITE COMMENTS. I WILL BE AWARE OF EACH COMMENTARY AND MAY COME BACK WITH A REPLY.

TO FIND A TOPIC OF INTEREST TO YOU ON THIS BLOG, SIMPLY TYPE IN THE NAME OR WORDS RELATED TO THE TOPIC IN THE FIELD IN THE LEFT HAND SIDE AT TOP OF THE PAGE AND THEN CLICK ON “SEARCH BLOG”. WITH WELL OVER 900 TOPICS, MOST ABOUT GENERAL OR SPECIFIC ETHICAL ISSUES BUT NOT NECESSARILY RELATED TO ANY SPECIFIC DATE OR EVENT, YOU SHOULD BE ABLE TO FIND WHAT YOU WANT. IF YOU DON’T PLEASE WRITE TO ME ON THE FEEDBACK THREAD OR BY E-MAIL DoktorMo@aol.com

IMPORTANT REQUEST TO ALL WHO COMMENT ON THIS BLOG: ALL COMMENTERS WHO WISH TO SIGN ON AS ANONYMOUS NEVERTHELESS PLEASE SIGN OFF AT THE END OF YOUR COMMENTS WITH A CONSISTENT PSEUDONYM NAME OR SOME INITIALS TO HELP MAINTAIN CONTINUITY AND NOT REQUIRE RESPONDERS TO LOOK UP THE DATE AND TIME OF THE POSTING TO DEFINE WHICH ANONYMOUS SAID WHAT. Thanks. ..Maurice

FEEDBACK,FEEDBACK,FEEDBACK! WRITE YOUR FEEDBACK ABOUT THIS BLOG, WHAT IS GOOD, POOR AND CONSTRUCTIVE SUGGESTIONS FOR IMPROVEMENT TO THIS FEEDBACK THREAD

Monday, July 14, 2008

A Doctor's Touch

Touching a patient is one important act which a physician can perform. Although it is no longer performed in the manner pictured in the medical textbooks graphics of the 19th century (see Addendum below), it is an act which we teach our medical students all about as they learn to first experience the relationship with a patient previously unknown to them.

Touching the patient, perhaps at first as a handshake, provides the first connection with the patient. It can be represented as the marking of a beginning doctor-patient relationship which is hopefully to continue to the benefit of the patient. The quality of the handshake tells each party, at the onset, something about the other. As the patient relates the history of illness and his or her life experiences, the physician’s touch at a moment the patient demonstrates emotional distress, a touch of the physician’s hand on the patient’s arm or shoulder shows the physician is aware of the distress and is present to be supportive.

The act of touching continues into the physical examination where touching is termed palpation. Usually, the first touching in the physical exam occurs if the doctor, not the nurse, takes the patient’s vital signs blood pressure and pulse where touching is involved. It also may be the first time that the physician and patient are physically close to each other over a period of time and becomes a marker for what will continue throughout the examination to a more intimate professional relationship. Palpation is used extensively in the physical examination. Students are taught that it is important to attempt to create a warm hand to examine the patient, since the results of touch with a cold hand can be that of patient discomfort and erroneous findings. The doctor’s touch during the exam not only discovers areas of the body which are painful to touch but also the doctor learns about the warmth of the patient’s skin, its texture, moisture and elasticity. In addition, the touch can reveal whether there is crepitation or crackling of the tissues under the skin or in the joints which may represent pathology. Touch also reveals sound vibrations from the lungs or heart or masses within the patient’s skin, below the skin, in the boney skeleton and within the cavities of the body. A doctor’s touch continues throughout the physical exam and shouldn’t stop when the exam is over and a discussion of the findings and conclusion occurs. Here the light but continuing touch of a patient’s arm or hand, particularly while conclusions upsetting to the patient must be presented, can represent that the physician intends to remain in contact and supportive for the patient as the medical care begins or continues.

Simple touching can be emotionally touching for both the patient and even occasionally for the physician, however touching should be part of the entire professional actions where the intent by the physician is solely for the benefit of the patient. The issue of hugging is a more controversial aspect of touching and I have already devoted another thread to this subject.

In conclusion, as you can see, a doctor’s touch is an action which, if used wisely and professionally can provide a variety of benefits from psychological to diagnostic. Also, you can see that touch is missing when the doctor-patient relationship involves phone, video or e-mail communication. It is understandable why we who teach medical students stress touch as an important medical tool in its many ways. ..Maurice.

Classic illustration of a woman's medical exam by her doctor. Many 19th century medical textbooks used this illustration to show the proper manner to examine a female patient. The physician's eyes are diverted so he will not violate the woman's "modesty."

10 Comments:

I wish schools would stop teaching medical students that the doctor should EXPECT to touch patients in the first meeting, as an act of healing or connection to the patient. Along with this, I also wish schools would teach the principle of ASKING before any and each instance of touching.

Yes, patients "should" expect to be touched as part of medical care. Yet, many patients also have backgrounds of being abused (as a child or as a spouse). Most abuse survivors detest the thought of being touched without being asked first. Most abuse survivors do not feel physician's touch as healing, but instead, survivors view this contact as intrusive actions they must "endure" to get medical care. When physicians don't ask first, the feeling of "enduring" unwanted contact increases.

Most abuse survivors choose not to reveal their histories of being survivors of childhood abuse or spousal abuse/domestic violence. Revealing abuse histories often leads to physicians treating these patients as though ALL physical symptoms are "somaticizing." Therefore, why would any survivor want to reveal such private information, only to be treated differently (and often with a negative attitude)?

Since survivors don't feel they can be forthcoming about their pasts, physicians must become more aware that any patient might (could) be a survivor of past abuse. Physicians should treat all patients with rights to say who can - and can't - touch them. And to say NO to any touch, at any time.

That may seem silly. After all, patients willingly come to see physicians, supposedly for medical help. Getting medical help requires a degree of touch (at minimum: vital signs, palpatation of a body part, close contact to the patient's body). However, just because a patient comes to a doctor, the doctor should not assume a right to (so-called) healing touch. Instead, ASK first.

Asking helps patients maintain their rights over their bodies, and helps survivors reconnect with their own sense of power (rather than the powerlessness that persists after abuse). Asking helps survivors prepare emotionally for any flashbacks that might occur while a physician performs the role of medical touch. Lastly, asking helps survivors of abuse maintain control-- over their emotions, current situation, etc.

Asking a patient before touching establishes much more of a "connection" in the doctor-patient relationship, than the benefits of "healing touch" when physicians just assume is okay to touch patients. Asking communicates a level of respect and treating patients as adults than the still-prevalent paternalistic attitudes doctors maintain.

Medical schools teach for only 30 minutes to an hour on child abuse -- mostly about mandatory reporting of minors suffering abuse. Little or no instruction is given about how to recognize or interact with adult survivors of abuse. Schools must start teaching medical students about adult survivors' needs.

"Healing touch" is much over-rated when physicians don't consider each patient's background!

In comment to Lifes' post, it doesn't necessarily have anything to do with abuse. There are a significant number of people out there that, whether for cultural influence or personal preference, simply do not like to be touched or to have their personal space invaded.

I agree wholeheartedly that a provider should ALWAYS ask first, and that a patient has the absolute right to say "stop" or "no" to anything they are not comfortable with.

With regard to asking permission for a handshake, the extended arm and hand of the doctor as the doctor makes the introduction is equivalent to asking. Beyond that, asking is implied by the doctor by providing to the patient timely information about the upcoming touching such as "now I will feel in your abdomen for your liver and spleen". At this point the patient could ask additional information "will it hurt?" or refuse the touching. It is unreasonable for a physician to ask and wait for the patient's permission for each one of the dozens of touching actions required for a thorough physical exam. Patients, who have no prior experience or knowledge of what happens in a physical exam have to take some responsibility to inform the doctor in advance their innocence about the exam and the physician should explain and answer their questions. Once the patient accepts starting the exam, it is then implied that the exam can continue with the doctor providing simple explanations througout the process as noted above.

With regard to physician identification of patients who have a past history of physical, mental or sexual abuse, it can be quite difficult without the patient coming straight out with the story of abuse. Otherwise, similar to physicians having to suspect or diagnose other medical conditions, it requires a systematic analysis of facts in the history which would suggest abuse. And yes, doctors need more training in the most effective and humanistic methods to understand and help abused patients. ..Maurice.

I will be going to my first appointment with a urologist next week. Although I am not sure exactly what to expect, I have no great doubt that I am going to get touched...I have no idea how this doctor conducts his exams..or what he is going to do. But I can guess...prostate problems + testicular problems = getting touched... I admit being nervous.I can only hope he doesn't need an assistant....If I was not going to allow him to touch me, I probably would be better off finding someone with a crystal ball..leemacaz

By the way, there is strong reasons for patients to touch themselves, particularly related to the early discovery of testicular diseases. Palpation is far better technique to pickup pathology than gazing into a crystal ball. ..Maurice.

I hope you know that saying anything about a crystal ball was my way of saying that I understand that palpation is an important part of how a doctor determines what is going on...and that without it I would be leaving the doctor no more chance than if I used a crystal ball... As much as I dislike being touched, I am realistic enough to know that there is little point in going to a doctor if he can never touch me.My concerns and nervousness are several other items...one is not knowing what he may find.. the other is strictly a modesty issue.I do not think this urologist is going to be touching any more than he has to..only the unavoidable parts of the exam.leemacaz

The urologist only touched (manipulated/ palpated) testicles where ultrasound had shown something...told me it was nothing to be concerned about...my PCP was just being cautious..I ws releived it was nothing serious and very gratefull that I never had to say one word about being exposed needlessly to anyone.leemacaz

I just visited a new doctor for a second opinion and evidently I frustrated him in my format of answers/word choices. He consistently cut me off 2-3 words into responses and told me not to use the word "inflammation" as I wasn't "a doctor" and shouldnt use medical terms...I was in my gown from the waist up sitting at the table beside him and he GRABBED my wrist, then acted to be "consoling" me...It was not a gentle touch, nor consoling-scary rather...I absolutely froze,(and in my head screamed "don't touch me") and was crying throughout the entire rest of the exam. He then acted "overly" nice the rest of the exam. I think because he knew he crossed a line. Noone else was in the room when this happened, but everyone in the office knows I was distraught due to the tears still when I left and when nurses were in the room....Was he inappropriate? What do I do? File a complaint with the hospital...police, attorney? I have thrown up twice today from being upset that he grabbed me. What makes it worse was his "overplay" of being nice and informational later!!

Patients should be honest if we’ve been molested or abused. I don’t feel like I need to give my life story in so doing but I will say, “I’ve been abused and molested by females; I want to see a male doc/don’t want a female healthcare provider to touch me at all” (note: some of those women were female doctors). I don’t care where males touch me and my buddies touch me literally everywhere; males have never abused me so it’s not an issue. I think that a doctor’s touch is incredibly important; even hugs are great. Additionally, I’ve never actually had a problem seeing a male doc. I’ve had woman doctors who have thrown a hissy fit over my “sexism” but frankly I don’t care. I used to defend myself but honestly, it’s abuse-driven sexism. Maybe slightly more justifiable but not that much. For physicians, I will tell you this. Once you know this information, ask first if your gender is an issue and offer to get a doctor of the other gender if possible or reschedule. If gender is not a big deal to the patient, ask what their triggers are. Mine are, for example, having a female behind me where I cannot see her actions, having her touch my shoulders, chest, face or back and genitals. I indicate that these are not OK places and we get a male doc in there to proceed since there’s no way that she could perform an exam if not at least allowed to touch my face or back. But you might get a patient whose triggers are their bellies only. In that case, just avoid the belly if possible.Some people who have been abused manage to compartmentalise their abuse. I.e someone who was raped by men but still marries a man probably can compartmentalise their abusive past long enough to allow a male doctor to examine them but you have folks like me who do not like females to touch them at all. I even use a Japanese bow instead of a handshake. I allow my own mother to give me a “Christian side hug” but nothing more.

A couple of things: For those who sign on as "Anonymous", to provide continuity, please end your comments with a consistent pseudonym so the readers will know who wrote or responded to who.

Finally, it may be of interest for those who have come to this blog thread to know that we have another blog thread titled "Patient Modesty" to which the reader here may be interested to read, contribute and follow. The thread started in 2005 and has continued Volume after Volume over the years each with 150-189 Comments in each Volume and currently we are at Volume 80.The topic of that thread involves the physical modesty beyond simply "touching" but what physical modesty and dignity is all about. ..Maurice.

The content of this blog is Copyrighted 2004-14. Maurice Bernstein, M.D. All Rights Reserved

FAIR USE NOTICE:

If this site contains copyrighted material the use of which has not been specifically authorized by the copyright owner, it is being made available in an effort to advance the understanding of the ethics dealing with medical practice, medical care, science and scientific research, human rights, social justice and, in addition, the law and politics which cover these areas. It is believed that this use constitutes a 'fair use' of any such copyrighted material as provided for in section 107 of the US Copyright Law. In accordance with Title 17 U.S.C. Section 107, the material on this site is distributed to visitors of this “Bioethics Discussion Blog” without profit to the blog or to those who by visiting this blog have expressed interest in receiving the included information for research and educational purposes. If you wish to use copyrighted material from this site for purposes of your own that go beyond 'fair use', you must obtain permission from the copyright owner.

The material in this site is provided for educational and informational purposes only, and is not intended to be a substitute for a health care provider's consultation. Please consult your own appropriate health care provider about the applicability of any opinions or recommendations with respect to your own symptoms or medical conditions. The information on this site does not constitute legal or technical advice.